This is the second of a five-part series on modernizing medicare: lessons from home and abroad

Josée Lavoie is a professor in the Department of Community Health Sciences, and director of the Manitoba First Nations Centre for Aboriginal Health Research, at the University of Manitoba. Shewill be presenting at the AMS Healthcare Symposium – Canadian Medicare 2017: Historical Reflections, Future Directions – in Toronto on May 11-12

In 2017, there remains a health-care system in Canada excluded from the shelter of the 1984 Canada Health Act. Funded by the First Nations and Inuit Health Branch of Health Canada (FNIHB), Canada's 14th health-care system operates outside of the legislative framework of the 13 provinces and territories. It operates on First Nation reserves across Canada and in the Inuit communities of northern Quebec and Labrador.

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Ample evidence shows that Canadians faced with serious health issues experience considerable challenges navigating their provincial health-care system. For First Nations and Inuit patients, this is compounded by having to continuously cross jurisdictional boundaries to access the care they need – They are faced with additional challenges because federal and provincial authorities often disagree on which system should pay for which services.

Studies have shown that jurisdictional confusion creates barriers to First Nations and Inuit accessing services other Canadians can expect. Despite having been involved in the funding and delivery of health services to First Nations and Inuit since 1945, the federal government has yet to clearly define its obligations to First Nations and Inuit in relation to the provision of health services.

As a solution, some have suggested that the federal government transfer all obligations for health-service delivery to the provinces. Such a transfer, it is argued, will finally end all jurisdictional confusion. However, shifting all federal responsibilities for First Nation and Inuit health care to the provinces is ill-advised and will not achieve the objective sought.

More than 80 per cent of First Nations and Inuit communities now manage their own community-based health services. Evidence shows that these communities have better health outcomes. Shifting federal responsibilities to the provinces will not necessarily eliminate cross-jurisdictional issues, unless part of this plan is also to transfer responsibilities now shouldered by First Nations and Inuit communities to the provinces. This would go against our constitutional commitment to support self-government activities, and is unlikely.

Every provincial health-care system manages a multiplicity of players including provincial health authorities, hospitals, community clinics, family physicians in private practices, and others. Legislation, policies and clarity over roles and responsibilities ensure that services are complementary and reasonably co-ordinated. Mechanisms exist to rectify problems. This is precisely what is missing when confusion emerges between the 14th health-care system and its provincial counterpart.

Last fall, Canada began renegotiating a new health-care accord. By all accounts, first ministers' discussions were difficult and failed to produce a consensus agreement. Separate agreements have been secured with all provinces and territories, with the notable exception of Manitoba. Although Indigenous political organizations were given the opportunity to address the first ministers, agreements focused exclusively on federal-provincial/territorial relations and excluded the 14th health-care system.

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As a unique instrument of cross-jurisdictional co-ordination, new health accord agreements should include a more explicit commitment to health equity for all Indigenous Canadians; clarify federal and provincial jurisdictional obligations; establish effective mechanisms for addressing areas of jurisdictional dispute and/or confusion; and explicitly recognize First Nations' and Inuit's health-care services as integral yet distinct systems, that nevertheless must be supported to seamlessly work with provincial health-care systems, to ensure continuity of care.

It is time to implement mechanisms to address long-standing challenges including jurisdictional disputes and confusion, and welcome the 14th health-care system as an equal partner with its 13 other counterparts. The status quo is perpetuating inequities, misery and associated higher health-care costs. The time for fundamental health-policy renewal is long overdue.

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